PATHOLOGY REQUEST FORM REGISTRATION

LAB NUMBER

Patient's Surname		Patient's Given Name		Gender	Unknown Male Female
Patient's D.O.B.		Patient's UR Number		WARD	Unknown OutPatient DEM Ward 1	UNIT	Unknown Medical Surgical Gynae Paediatrics
Specimen Date		Specimen Time		BILLING	Free Full Fee 85% Fee 50% Fee Other

TUBE TYPES RECEIVED
Serum Plasma Glucose FBE/EDTA Coags Spot Urine 24hr Urine Fluid Tube Blood Cultures Swab(s) Histology Sample(s) Cytology (PAP) Sample Other Tubes

SELECT THE TESTS REQUESTED FROM THE DROP DOWN LISTS

To SELECT MULTIPLE tests from a list hold down the CTRL key at the same time as you click the LEFT MOUSE BUTTON.

BIOCHEMISTRY Na, K Creat LFT`S Ca, Mg Phos CK & CKMB GLUCOSE Serum Osmolality Urine Osmolality Amylase Cholesterol Triglyceride HDL Neonatal Bili CRP Lithium Alcohol Paracetamol Salicylate Carbamezapine Theophylline Digoxin Phenytoin Haemoglobin A1c Iron Studies HAEMATOLOGY FBC COAGS PTT INR ESR B12 & Folate D-Dimers MICROBIOLOGY Urine M, C & S Swab Blood Cultures Gentamicin-Random Gentamicin-PRE Dose Gentamicin-POST Dose Vancomycin-Random Vancomycin-PRE Dose Vancomycin-POST Dose ENDOCRINOLOGY TFT T4 TSH Beta HCG Progesterone Oestradiol Cortisol Prolactin Growth Hormone Insulin C-Peptide ACTH PTH SHBG ADH FSH Gastrin

SPUTUM Oropharyngeal Endotracheal Asp. Lavage STOOL OCP MCS C.difficile Toxin CSF Cell Count Protein & Gluc Routine MCS

Swab Sites

Patient Pregnant Gestational Weeks

HIV TEST - This Request will only be processed on receipt of a Request Form signed by the doctor and by the patient

OTHER TESTS NOT LISTED - One per line please

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Clinical Notes

Doctor's Surname

Copy of Reports to

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LABMAN SOLO
Screen1 : November 2004 : email tom@medlabstats.com